System and method for sustained baroreflex stimulation

ABSTRACT

Various aspects of the present subject matter provide an implantable medical device. In various embodiments, the device comprises a baroreflex stimulator and a controller. The baroreflex stimulator is adapted to generate a stimulation signal to stimulate a baroreflex. The controller is adapted to communicate with the baroreflex stimulator and implement a baroreflex stimulation protocol to vary an intensity of the baroreflex stimulation provided by the stimulation signal to abate baroreflex adaptation. According to various embodiments, the controller is adapted to implement the baroreflex stimulation protocol to periodically modulate the baroreflex stimulation to produce an effect that mimics an effect of pulsatile pressure. Other aspects are provided herein.

CLAIM OF PRIORITY

This application is a continuation of and claims the benefit of priorityunder 35U.S.C. §120 to U.S. patent application Ser. No. 10/962,845,filed on Oct. 12, 2004, which is hereby incorporated by reference hereinin its entirety.

TECHNICAL FIELD

This application relates generally to neural stimulators and, moreparticularly, to systems, devices and methods for sustaining baroreflexstimulation.

BACKGROUND

Implanting a chronic electrical stimulator, such as a cardiacstimulator, to deliver medical therapy(ies) is known. Examples ofcardiac stimulators include implantable cardiac rhythm management (CRM)devices such as pacemakers, implantable cardiac defibrillators (ICDs),and implantable devices capable of performing pacing and defibrillatingfunctions.

Implantable CRM devices provide electrical stimulation to selectedchambers of the heart in order to treat disorders of cardiac rhythm. Animplantable pacemaker, for example, is a CRM device that paces the heartwith timed pacing pulses. If functioning properly, the pacemaker makesup for the heart's inability to pace itself at an appropriate rhythm inorder to meet metabolic demand by enforcing a minimum heart rate. SomeCRM devices synchronize pacing pulses delivered to different areas ofthe heart in order to coordinate the contractions. Coordinatedcontractions allow the heart to pump efficiently while providingsufficient cardiac output.

Heart failure refers to a clinical syndrome in which cardiac functioncauses a below normal cardiac output that can fall below a leveladequate to meet the metabolic demand of peripheral tissues. Heartfailure may present itself as congestive heart failure (CHF) due to theaccompanying venous and pulmonary congestion. Heart failure can be dueto a variety of etiologies such as ischemic heart disease.

Hypertension is a cause of heart disease and other related cardiacco-morbidities. Hypertension occurs when blood vessels constrict. As aresult, the heart works harder to maintain flow at a higher bloodpressure, which can contribute to heart failure. A large segment of thegeneral population, as well as a large segment of patients implantedwith pacemakers or defibrillators, suffer from hypertension. The longterm mortality as well as the quality of life can be improved for thispopulation if blood pressure and hypertension can be reduced. Manypatients who suffer from hypertension do not respond to treatment, suchas treatments related to lifestyle changes and hypertension drugs.

A pressoreceptive region or field is capable of sensing changes inpressure, such as changes in blood pressure. Pressoreceptor regions arereferred to herein as baroreceptors, which generally include any sensorsof pressure changes. For example, baroreceptors include sensory nerveendings that are sensitive to the stretching of die wall that resultsfrom increased blood pressure from within, and function as the receptorof a central reflex mechanism that tends to reduce the pressure.Baroreflex functions as a negative feedback system, and relates to areflex mechanism triggered by stimulation of a baroreceptor.Additionally, baroreflex can be triggered by stimulation of afferentnerves. Increased pressure stretches blood vessels, which in turnactivates baroreceptors in the vessel walls. Activation of baroreceptorsnaturally occurs through internal pressure and stretching of thearterial wall, causing baroreflex inhibition of sympathetic nerveactivity (SNA) and a reduction in systemic arterial pressure. Anincrease in baroreceptor activity induces a reduction of SNA, whichreduces blood pressure by decreasing peripheral vascular resistance.

The general concept of stimulating afferent nerve trunks leading frombaroreceptors is known. For example, direct electrical stimulation hasbeen applied to the vagal nerve and carotid sinus. Research hasindicated that electrical stimulation of the carotid sinus nerve canresult in reduction of experimental hypertension, and that directelectrical stimulation to the pressoreceptive regions of the carotidsinus itself brings about reflex reduction in experimental hypertension.Research further has indicated that the baroreflex quickly adapts toincreased baroreflex stimulation. Electrical systems have been proposedto treat hypertension in patients who do not otherwise respond totherapy involving lifestyle changes and hypertension drugs, and possiblyto reduce drug dependency for other patients.

The baroreflex adapts to increased baroreflex stimulation. Static orconstant baroreflex stimulation causes a quick or immediate responsewhich gradually diminishes. Over time, the baroreflex resets and returnsto the baseline response, which renders static stimulation ineffective.Thus, baroreflex adaptation poses a problem for sustaining baroreflextherapy that effectively inhibits SNA.

SUMMARY

Various aspects of the present subject matter provide an implantablemedical device. In various embodiments, the device comprises abaroreflex stimulator and a controller. The baroreflex stimulator isadapted to generate a stimulation signal to stimulate a baroreflex. Thecontroller is adapted to communicate with the baroreflex stimulator andimplement a baroreflex stimulation protocol to vary an intensity of thebaroreflex stimulation provided by the stimulation signal to abatebaroreflex adaptation. According to various embodiments, the controlleris adapted to implement the baroreflex stimulation protocol toperiodically modulate the baroreflex stimulation to produce an effectthat mimics an effect of pulsatile pressure.

Various aspects and embodiments of the present subject matter provide animplantable medical system, comprising means for generating a baroreflexstimulation signal to stimulate a baroreflex, and means for abatingbaroreflex adaptation, including means for periodically changing atleast one parameter of the baroreflex stimulation signal such that thebaroreflex stimulation ranges within a range from a first baroreflexstimulation level and a second baroreflex stimulation level. Accordingto various embodiments, the implantable medical system comprises asingle implantable device; and according to various embodiments, theimplantable medical system comprises an implantable neuro stimulator(NS) device and an implantable cardiac rhythm management (CRM) device.

Various aspects and embodiments of the present subject matter provide amethod, comprising generating a baroreflex stimulation signal tostimulate a baroreflex, and abating baroreflex adaptation, includingchanging at least one parameter of the baroreflex stimulation signalsuch that the baroreflex stimulation ranges within a range from a firstbaroreflex stimulation level and a second baroreflex stimulation level.According to various embodiments, the baroreflex stimulation signal ismodulated to mimic an effect of pulsatile pressure. In variousembodiments, a frequency, an amplitude, and/or a duty cycle of thebaroreflex stimulation signal are periodically changed.

This Summary is an overview of some of the teachings of the presentapplication and not intended to be an exclusive or exhaustive treatmentof the present subject matter. Further details about the present subjectmatter are found in the detailed description and appended claims. Otheraspects will be apparent to persons skilled in the art upon reading andunderstanding the following detailed description and viewing thedrawings that form a part thereof, each of which are not to be taken ina limiting sense. The scope of the present invention is defined by theappended claims and their equivalents.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A and 1B illustrate neural mechanisms for peripheral vascularcontrol.

FIG. 2 illustrates a heart.

FIG. 3 illustrates baroreceptors and afferent nerves in the area of thecarotid sinuses and aortic arch.

FIG. 4 illustrates baroreceptors in and around the pulmonary artery.

FIG. 5 illustrates baroreceptor fields in the aortic arch, theligamentum arteriosum and the trunk of the pulmonary artery.

FIG. 6 illustrates a known relationship between respiration and bloodpressure when the baroreflex is stimulated.

FIG. 7 illustrates a blood pressure response to carotid nervestimulation in a hypertensive dog during 6 months of intermittentcarotid nerve stimulation.

FIG. 8 illustrates a system including an implantable medical device(IMD) and a programmer, according to various embodiments of the presentsubject matter.

FIG. 9 illustrates an implantable medical device (IMD) such as shown inthe system of FIG. 8, according to various embodiments of the presentsubject matter.

FIG. 10 illustrates an implantable medical device (IMD) such as shown inFIG. 8 having a neural stimulator (NS) component and cardiac rhythmmanagement (CRM) component, according to various embodiments of thepresent subject matter.

FIG. 11 illustrates a system including a programmer, an implantableneural stimulator (NS) device and an implantable cardiac rhythmmanagement (CRM) device, according to various embodiments of the presentsubject matter.

FIG. 12 illustrates a programmer such as illustrated in the systems ofFIGS. 8 and 11 or other external device to communicate with theimplantable medical device(s), according to various embodiments of thepresent subject matter.

FIG. 13 illustrates baroreflex adaptation using a relationship betweencarotid sinus pressure, sympathetic nerve activity (SNA) and meanarterial pressure (MAP).

FIG. 14 is a graphical illustration of the relationship between a changein blood pressure and a rate of a stimulation signal.

FIG. 15 illustrates a method to periodically modulate neuralstimulation, according to various embodiments of the present subjectmatter.

FIG. 16 illustrates a neural stimulation device, according to variousembodiments of the present subject matter.

FIG. 17 illustrates an implantable neural stimulation (NS) device withsensing and/or detecting capabilities, according to various embodimentsof the present subject matter.

FIG. 18 illustrates a system including an implantable neural stimulation(NS) device and an implantable cardiac rhythm management (CRM) device,according to various embodiments of the present subject matter.

FIG. 19A illustrates a pulse and FIGS. 19B-19D illustrate variousstimulation protocol embodiments to modulate a stimulation signal basedon the pulse.

FIG. 20A illustrates a pulse and FIG. 20B illustrates an example of aburst frequency modulation protocol to mimic effects of pulsatilepressure.

DETAILED DESCRIPTION

The following detailed description of the present subject matter refersto the accompanying drawings which show, by way of illustration,specific aspects and embodiments in which the present subject matter maybe practiced. These embodiments are described in sufficient detail toenable those skilled in the art to practice the present subject matter.Other embodiments may be utilized and structural, logical, andelectrical changes may be made without departing from the scope of thepresent subject matter. References to “an” “one”, or “various”embodiments in this disclosure are not necessarily to the sameembodiment, and such references contemplate more than one embodiment.The following detailed description is, therefore, not to be taken in alimiting sense, and the scope is defined only by the appended claims,along with the full scope of legal equivalents to which such claims areentitled.

Hypertension and Baroreflex Physiology

A brief discussion of hypertension and the physiology related tobaroreceptors is provided to assist the reader with understanding thisdisclosure. This brief discussion introduces hypertension, the autonomicnervous system, and baroreflex.

Hypertension is a cause of heart disease and other related cardiacco-morbidities. Hypertension generally relates to high blood pressure,such as a transitory or sustained elevation of systemic arterial bloodpressure to a level that is likely to induce cardiovascular damage orother adverse consequences. Hypertension has been arbitrarily defined asa systolic blood pressure above 140 mm Hg or a diastolic blood pressureabove 90 mm Hg. Hypertension occurs when blood vessels constrict. As aresult, the heart works harder to maintain flow at a higher bloodpressure. Consequences of uncontrolled hypertension include, but are notlimited to, retinal vascular disease and stroke, left ventricularhypertrophy and failure, myocardial infarction, dissecting aneurysm, andrenovascular disease.

The automatic nervous system (ANS) regulates “involuntary” organs, whilethe contraction of voluntary (skeletal) muscles is controlled by somaticmotor nerves. Examples of involuntary organs include respiratory anddigestive organs, and also include blood vessels and the heart. Often,the ANS functions in an involuntary, reflexive manner to regulateglands, to regulate muscles in the skin, eye, stomach, intestines andbladder, and to regulate cardiac muscle and the muscle around bloodvessels, for example.

The ANS includes, but is not limited to, the sympathetic nervous systemand the parasympathetic nervous system. The sympathetic nervous systemis affiliated with stress and the “fight or flight response” toemergencies. Among other effects, the “fight or flight response”increases blood pressure and heart rate to increase skeletal muscleblood flow, and decreases digestion to provide the energy for “fightingor fleeing.” The parasympathetic nervous system is affiliated withrelaxation and the “rest and digest response” which, among othereffects, decreases blood pressure and heart rate, and increasesdigestion to conserve energy. The ANS maintains normal internal functionand works with the somatic nervous system.

The subject matter of this disclosure generally refers to the effectsthat the ANS has on the heart rate and blood pressure, includingvasodilation and vasoconstriction. The heart rate and force is increasedwhen the sympathetic nervous system is stimulated, and is decreased whenthe sympathetic nervous system is inhibited (the parasympathetic nervoussystem is stimulated). FIGS. 1A and 1B illustrate neural mechanisms forperipheral vascular control. FIG. 1A generally illustrates afferentnerves to vasomotor centers. An afferent nerve conveys impulses toward anerve center. A vasomotor center relates to nerves that dilate andconstrict blood vessels to control the size of the blood vessels. FIG.1B generally illustrates efferent nerves from vasomotor centers. Anefferent nerve conveys impulses away from a nerve center.

Stimulating the sympathetic and parasympathetic nervous systems can haveeffects other than heart rate and blood pressure. For example,stimulating the sympathetic nervous system dilates the pupil, reducessaliva and mucus production, relaxes the bronchial muscle, reduces thesuccessive waves of involuntary contraction (peristalsis) of the stomachand the motility of the stomach, increases the conversion of glycogen toglucose by the liver, decreases urine secretion by the kidneys, andrelaxes the wall and closes the sphincter of the bladder. Stimulatingthe parasympathetic nervous system (inhibiting the sympathetic nervoussystem) constricts the pupil, increases saliva and mucus production,contracts the bronchial muscle, increases secretions and motility in thestomach and large intestine, and increases digestion in the smallintention, increases urine secretion, and contracts the wall and relaxesthe sphincter of the bladder. The functions associated with thesympathetic and parasympathetic nervous systems are many and can becomplexly integrated with each other. Thus, an indiscriminatestimulation of the sympathetic and/or parasympathetic nervous systems toachieve a desired response, such as vasodilation, in one physiologicalsystem may also result in an undesired response in other physiologicalsystems.

Baroreflex is a reflex triggered by stimulation of a baroreceptor. Abaroreceptor includes any sensor of pressure changes, such as sensorynerve endings in the wall of the auricles of the heart, vena cava,aortic arch and carotid sinus, that is sensitive to stretching of thewall resulting from increased pressure from within, and that functionsas the receptor of the central reflex mechanism that tends to reducethat pressure. Clusters of nerve cells can be referred to as autonomicganglia. These nerve cells can also be electrically stimulated to inducea baroreflex, which inhibits the sympathetic nerve activity andstimulates parasympathetic nerve activity. Autonomic ganglia thus formspart of a baroreflex pathway. Afferent nerve trunks, such as the vagus,aortic and carotid nerves, leading from the sensory nerve endings alsoform part of a baroreflex pathway. Stimulating a baroreflex pathwayand/or baroreceptors inhibits sympathetic nerve activity (stimulates theparasympathetic nervous system) and reduces systemic arterial pressureby decreasing peripheral vascular resistance and cardiac contractility.Baroreceptors are naturally stimulated by internal pressure and thestretching of vessel wall (e.g. arterial wall).

Some aspects of the present subject matter locally stimulate specificnerve endings in arterial walls rather than stimulate afferent nervetrunks in an effort to stimulate a desire response (e.g. reducedhypertension) while reducing the undesired effects of indiscriminatestimulation of the nervous system. For example, some embodimentsstimulate baroreceptor sites in the pulmonary artery. Some embodimentsof the present subject matter involve stimulating baroreceptor sites ornerve endings in the aorta and the chambers of the heart, and someembodiments of the present subject matter involve stimulating anafferent nerve trunk, such as the vagus, carotid and aortic nerves. Someembodiments stimulate afferent nerve trunks using a cuff electrode, andsome embodiments stimulate afferent nerve trunks using an intravascularlead positioned in a blood vessel proximate to the nerve, such that theelectrical stimulation passes through the vessel wall to stimulate theafferent nerve trunk.

FIG. 2 illustrates a heart. The heart 201 includes a superior vena cava202, an aortic arch 203, and a pulmonary artery 204, and is useful toprovide a contextual relationship with the illustrations in FIGS. 3-5.As is discussed in more detail below, the pulmonary artery 204 includesbaroreceptors. A lead is capable of being intravascularly insertedthrough a peripheral vein and through the tricuspid valve into the rightventricle of the heart (not expressly shown in the figure) similar to acardiac pacemaker lead, and continue from the right ventricle throughthe pulmonary valve into the pulmonary artery. A portion of thepulmonary artery and aorta are proximate to each other. Variousembodiments stimulate baroreceptors in the aorta using a leadintravascularly positioned in the pulmonary artery. Thus, according tovarious aspects of the present subject matter, the baroreflex isstimulated in or around the pulmonary artery by at least one electrodeintravascularly inserted into the pulmonary artery. Alternatively, awireless stimulating device, with or without pressure sensingcapability, may be positioned via catheter into the pulmonary artery.Control of stimulation and/or energy for stimulation may be supplied byanother implantable or external device via ultrasonic, electromagneticor a combination thereof. Aspects of the present subject matter providea relatively noninvasive surgical technique to implant a baroreflexstimulator intravascularly into the pulmonary artery.

FIG. 3 illustrates baroreceptors in the area of the carotid sinus 305,aortic arch 303 and pulmonary artery 304. The aortic arch 303 andpulmonary artery 304 were previously illustrated with respect to theheart in FIG. 2. As illustrated in FIG. 3, the vagus nerve 306 extendsand provides sensory nerve endings 307 that function as baroreceptors inthe aortic arch 303, in the carotid sinus 305 and in the common carotidartery 310. The glossopharyngeal nerve 308 provides nerve endings 309that function as baroreceptors in the carotid sinus 305. These nerveendings 307 and 309, for example, are sensitive to stretching of thewall resulting from increased pressure from within. Activation of thesenerve endings reduce pressure. Although not illustrated in the figures,the atrial and ventricular chambers of the heart also includebaroreceptors. Cuffs have been placed around afferent nerve trunks, suchas the vagal nerve, leading from baroreceptors to vasomotor centers tostimulate the baroreflex. According to various embodiments of thepresent subject matter, afferent nerve trunks can be stimulated using acuff or intravascularly-fed lead positioned in a blood vessel proximateto the afferent nerves.

FIG. 4 illustrates baroreceptors in and around a pulmonary artery 404.The superior vena cava 402 and the aortic arch 403 are also illustrated.As illustrated, the pulmonary artery 404 includes a number ofbaroreceptors 411, as generally indicated by the dark area. Furthermore,a cluster of closely spaced baroreceptors is situated near theattachment of the ligamentum arteriosum 412. FIG. 4 also illustrates theright ventricle 413 of the heart, and the pulmonary valve 414 separatingthe right ventricle 413 from the pulmonary artery 404. According tovarious embodiments of the present subject matter, a lead is insertedthrough a peripheral vein and threaded through the tricuspid valve intothe right ventricle, and from the right ventricle 413 through thepulmonary valve 414 and into the pulmonary artery 404 to stimulatebaroreceptors in and/or around the pulmonary artery. In variousembodiments, for example, the lead is positioned to stimulate thecluster of baroreceptors near the ligamentum arteriosum 412. FIG. 5illustrates baroreceptor fields 511 in the aortic arch 503, near theligamentum arteriosum 512 and the trunk of the pulmonary artery 504.Some embodiments position the lead in the pulmonary artery to stimulatebaroreceptor sites in the aorta.

FIG. 6 illustrates a known relationship between respiration 615 andblood pressure 616 when the left aortic nerve is stimulated. When thenerve is stimulated at 617, the blood pressure 616 drops, and therespiration 615 becomes faster and deeper, as illustrated by the higherfrequency and amplitude of the respiration waveform. The respiration andblood pressure appear to return to the pre-stimulated state inapproximately one to two minutes after the stimulation is removed. Thisrelationship between respiration and blood pressure allows respirationto be used as a surrogate parameter for blood pressure.

FIG. 7 illustrates a known blood pressure response to carotid nervestimulation in a hypertensive dog during 6 months of intermittentcarotid nerve stimulation. The carotid nerve stimulation involvedturning on a carotid nerve stimulator once a month for up to six hours,and measuring the blood pressure response to monitor the stability ofthe acute response over long time periods. The figure illustrates thatthe blood pressure of a stimulated dog 718 is significantly less thanthe blood pressure of a control dog 719 that also has high bloodpressure. Thus, such stimulation is capable of triggering the baroreflexto reduce high blood pressure.

Baroreflex Stimulator Systems

Various embodiments of the present subject matter relate to baroreflexstimulator systems. Such baroreflex stimulation systems are alsoreferred to herein as neural stimulator (NS) devices or components.Examples of neural stimulators include anti-hypertension (AHT) devicesor AHT components that are used to treat hypertension. Variousembodiments of the present subject matter include stand-aloneimplantable baroreflex stimulator systems, include implantable devicesthat have integrated NS and cardiac rhythm management (CRM) components,and include systems with at least one implantable NS device and animplantable CRM device capable of communicating with each other eitherwirelessly or through a wire lead connecting the implantable devices.Although implantable systems are illustrated and discussed, variousaspects and embodiments of the present subject matter can be implementedin external NS devices. Integrating NS and CRM functions that are eitherperformed in the same or separate devices improves aspects of the NStherapy and cardiac therapy by allowing these therapies to intelligentlywork together.

FIG. 8 illustrates a system 820 including an implantable medical device(IMD) 821 and a programmer 822, according to various embodiments of thepresent subject matter. Various embodiments of the IMD 821 includeneural stimulator functions only, and various embodiments include acombination of NS and CRM functions. Some embodiments of the neuralstimulator provide AHT functions to treat hypertension. The programmer822 and the IMD 821 are capable of wirelessly communicating data andinstructions. In various embodiments, for example, the programmer 822and IMD 821 use telemetry coils to wirelessly communicate data andinstructions. Thus, the programmer can be used to adjust the programmedtherapy provided by the IMD 821, and the IMD can report device data(such as battery and lead resistance) and therapy data (such as senseand stimulation data) to the programmer using radio telemetry, forexample. According to various embodiments, the IMD 821 stimulatesbaroreceptors to provide NS therapy such as AHT therapy. Variousembodiments of the MD 821 stimulate baroreceptors in the pulmonaryartery using a lead fed through the right ventricle similar to a cardiacpacemaker lead, and further fed into the pulmonary artery. Otherembodiments stimulate other baroreceptor sites or baroreflex pathways.According to various embodiments, the IMD 821 includes a sensor to senseANS activity. Such a sensor can be used to perform feedback in a closedloop control system. For example, various embodiments sense surrogateparameters, such as respiration and blood pressure, indicative of ANSactivity. According to various embodiments, the IMD further includescardiac stimulation capabilities, such as pacing and defibrillatingcapabilities in addition to the capabilities to stimulate baroreceptorsand/or sense ANS activity.

FIG. 9 illustrates an implantable medical device (IMD) 921 such as theIMD 821 shown in the system 820 of FIG. 8, according to variousembodiments of the present subject matter. The illustrated IMD 921performs NS functions. Some embodiments of the illustrated IMD 921performs an AHT function to treat hypertension, and thus illustrates animplantable AHT device. The illustrated device 921 includes controllercircuitry 923 and a memory 924. The controller circuitry 923 is capableof being implemented using hardware, software, and combinations ofhardware and software. For example, according to various embodiments,the controller circuitry 923 includes a processor to performinstructions embedded in the memory 924 to perform functions associatedwith NS therapy such as AHT therapy. The memory 924 includesinstructions that correspond to a baroreflex stimulation protocol 928.The controller executes these instructions to implement the baroreflexstimulation protocol. For example, the illustrated device 921 furtherincludes a transceiver 925 and associated circuitry for use tocommunicate with a programmer or another external or internal device.Various embodiments have wireless communication capabilities. Forexample, some transceiver embodiments use a telemetry coil to wirelesslycommunicate with a programmer or another external or internal device.

The illustrated device 921 further includes baroreflex stimulationcircuitry 926 to stimulate a baroreflex by stimulating a baroreceptor orbaroreflex pathway such as afferent nerves. Various embodiments of thedevice 921 also includes sensor circuitry 927, illustrated as apulsatile rhythm detector to detect pulsatile parameters, according tovarious aspects and embodiments of the present subject matter. One ormore leads are able to be connected to the sensor circuitry 927 andbaroreflex stimulation circuitry 926. The baroreflex stimulationcircuitry 926 is used to apply electrical stimulation pulses to induce abaroreflex at desired baroreceptors sites, such as baroreceptor sites inthe pulmonary artery, and/or desired baroreflex pathway sites, such asafferent nerves, through one or more stimulation electrodes. In variousembodiments, the sensor circuitry 927 is further adapted to detect andprocess ANS nerve activity and/or surrogate parameters such as bloodpressure, respiration and the like, to determine the ANS activity andprovide closed loop feedback control.

According to various embodiments, the stimulator circuitry 926 includesa modulator 929 to modulate any one or any combination of two or more ofthe following pulse features: the amplitude of the stimulation pulse,the frequency of the stimulation pulse, the burst frequency or dutycycle of the pulse. Various embodiments provide stimulation signalshaving a morphology of a square wave, a sinusoidal wave, a triangle waveand/or a wave that has appropriate harmonic components to mimic whitenoise such as is indicative of naturally-occurring baroreflexstimulation.

FIG. 10 illustrates an implantable medical device (IMD) 1021 such asshown at 821 in FIG. 8 having a neural stimulation (NS), such as ananti-hypertension (AHT) component 1037 to treat hypertension, andcardiac rhythm management (CRM) component 1038, according to variousembodiments of the present subject matter. The illustrated device 1021includes a controller 1023 and a memory 1024. According to variousembodiments, the controller 1023 includes hardware, software, or acombination of hardware and software to perform the baroreflexstimulation and CRM functions. For example, the programmed therapyapplications discussed in this disclosure are capable of being stored ascomputer-readable instructions embodied in memory and executed by aprocessor. According to various embodiments, the controller 1023includes a processor to execute instructions embedded in memory toperform the baroreflex stimulation and CRM functions. The illustrateddevice 1021 further includes a transceiver 1025 and associated circuitryfor use to communicate with a programmer or another external or internaldevice. Various embodiments include a telemetry coil.

The CRM therapy section 1038 includes components, under the control ofthe controller, to stimulate a heart and/or sense cardiac signals usingone or more electrodes. The CRM therapy section includes a pulsegenerator 1039 for use to provide an electrical signal through anelectrode to stimulate a heart, and further includes sense circuitry1040 to detect and process sensed cardiac signals or otherwise detectpulsatile parameters according to the present subject matter. Aninterface 1041 is generally illustrated for use to communicate betweenthe controller 1023 and the pulse generator 1039 and sense circuitry1040. Three electrodes are illustrated as an example for use to provideCRM therapy. However, the present subject matter is not limited to aparticular number of electrode sites. One or more electrodes can bepositioned on a lead, and one or more leads can be used. Each electrodemay include its own pulse generator and sense circuitry. However, thepresent subject matter is not so limited. The pulse generating andsensing functions can be multiplexed to function with multipleelectrodes.

The NS therapy section 1037 includes components, under the control ofthe controller, to stimulate a baroreceptor and/or sense ANS parametersassociated with nerve activity or surrogates of ANS parameters such asblood pressure and respiration. Three interfaces 1042 are illustratedfor use to provide ANS therapy. However, the present subject matter isnot limited to a particular number interfaces, or to any particularstimulating or sensing functions. Pulse generators 1043 are used toprovide electrical pulses to an electrode for use to stimulate abaroreceptor site. According to various embodiments, the pulse generatorincludes circuitry to set, and in some embodiments change, the amplitudeof the stimulation pulse, the frequency of the stimulation pulse, theburst frequency of the pulse, and/or the morphology of the pulse such asa square wave, triangle wave, sinusoidal wave, and waves with desiredharmonic components to mimic white noise or other signals. Sensecircuits 1044 are used to detect and process signals from a sensor, suchas a sensor of pulsatile parameters, and/or a sensor of nerve activity,blood pressure, respiration, and the like. The interfaces 1042 aregenerally illustrated for use to communicate between the controller 1023and the pulse generator 1043 and sense circuitry 1044. Each interface,for example, may be used to control a separate lead. Various embodimentsof the NS therapy section only include a pulse generator to stimulatebaroreceptors. The NS therapy section is capable of providing AHTtherapy to treat hypertension, for example.

An aspect of the present subject matter relates to achronically-implanted stimulation system specially designed to treathypertension by monitoring blood pressure and periodically stimulatingbaroreceptors or a baroreflex pathway using a stimulation protocol toactivate the baroreflex and inhibit sympathetic discharge from thevasomotor center. Baroreceptors are located in various anatomicallocations such as the carotid sinus and the aortic arch. Otherbaroreceptor locations include the pulmonary artery, including theligamentum arteriosum, and sites in the atrial and ventricular chambers.Other baroreflex stimulation locations include baroreflex pathways suchas ganglia in cardiac fat pads and afferent nerve trunks. In variousembodiments, the system is integrated into a pacemaker/defibrillator orother electrical stimulator system. Components of the system include apulse generator, sensors to monitor blood pressure or other pertinentphysiological parameters, leads to apply electrical stimulation tobaroreceptors, algorithms to determine the appropriate time toadminister stimulation, and algorithms to manipulate data for displayand patient management.

Various embodiments relate to a system that seeks to deliverelectrically mediated NS therapy, such as AHT therapy, to patients.Various embodiments combine a “stand-alone” pulse generator with aminimally invasive, lead that stimulates baroreceptors and/or baroreflexpathways in the vicinity of the heart, such as in the pulmonary arteryor cardiac fat pad(s), using direct or transvenous stimulation, forexample. This embodiment is such that general medical practitionerslacking the skills of specialist can implant it. Various embodimentsincorporate a simple implanted system that can sense parametersindicative of blood pressure. This system adjusts the therapeutic output(waveform amplitude, frequency, etc.) so as to maintain a desiredquality of life. In various embodiments, an implanted system includes apulse generating device and lead system, the stimulating electrode ofwhich is positioned near endocardial baroreceptor tissues usingtransvenous implant technique(s). Another embodiment includes a systemthat combines NS therapy with traditional bradyarrhythmia,tachyarrhythmia, and/or congestive heart failure (CHF) therapies. Someembodiments use an additional “baroreflex lead” that emerges from thedevice header and is paced from a modified traditional pulse generatingsystem. In another embodiment, a traditional CRM lead is modified toincorporate proximal electrodes that are naturally positioned nearbaroreceptor sites. With these leads, distal electrodes provide CRMtherapy and proximate electrodes stimulate baroreceptors.

A system according to these embodiments can be used to augment partiallysuccessful treatment strategies. As an example, undesired side effectsmay limit the use of some pharmaceutical agents. The combination of asystem according to these embodiments with reduced drug doses may beparticularly beneficial.

According to various embodiments, the lead(s) and the electrode(s) onthe leads are physically arranged with respect to the heart in a fashionthat enables the electrodes to properly transmit pulses and sensesignals from the heart, and with respect to baroreceptors to stimulatethe baroreflex. As there may be a number of leads and a number ofelectrodes per lead, the configuration can be programmed to use aparticular electrode or electrodes. According to various embodiments,the baroreflex is stimulated by stimulating afferent nerve trunks.

FIG. 11 illustrates a system 1120 including a programmer 1122, animplantable neural stimulator (NS) device 1137 and an implantablecardiac rhythm management (CRM) device 1138, according to variousembodiments of the present subject matter. Various aspects involve amethod for communicating between an NS device 1137, such as an AHTdevice, and a CRM device 1138 or other cardiac stimulator. In variousembodiments, this communication allows one of the devices 1137 or 1138to deliver more appropriate therapy (i.e. more appropriate NS therapy orCRM therapy) based on data received from the other device. Someembodiments provide on-demand communications. In various embodiments,this communication allows each of the devices 1137 and 1138 to delivermore appropriate therapy (i.e. more appropriate NS therapy and CRMtherapy) based on data received from the other device. The illustratedNS device 1137 and the CRM device 1138 are capable of wirelesslycommunicating with each other, and the programmer is capable ofwirelessly communicating with at least one of the NS and the CRM devices1137 and 1138. For example, various embodiments use telemetry coils towirelessly communicate data and instructions to each other. In otherembodiments, communication of data and/or energy is by ultrasonic means.

In some embodiments, the NS device 1137 stimulates the baroreflex toprovide NS therapy. In some embodiments, the NS device 1137 furthersenses ANS activity directly or using surrogate parameters, such asrespiration and blood pressure, indicative of ANS activity. The CRMdevice 1138 includes cardiac stimulation capabilities, such as pacingand defibrillating capabilities. In some embodiments, the CRM deviceprovides pulsatile information. Rather than providing wirelesscommunication between the NS and CRM devices 1137 and 1138, variousembodiments provide a communication cable or wire, such as anintravenously-fed lead, for use to communicate between the NS device1137 and the CRM device 1138.

Some NS device embodiments are able to be implanted in patients withexisting CRM devices, such that the functionality of the NS device isenhanced by receiving physiological data that is acquired by the CRMdevice. The functionality of two or more implanted devices is enhancedby providing communication capabilities between or among the implanteddevices. In various embodiments, the functionality is further enhancedby designing the devices to wirelessly communicate with each other.

According to various embodiments, for example, the NS device is equippedwith a telemetry coil or ultrasonic transducer, allowing data to beexchanged between it and the CRM device, allowing the NS device toprovide NS therapy based no pulsatile information such as pulse rate andpulse phase. Embodiments of the NS device modify therapy based onelectrophysiological parameters such as heart rate, minute ventilation,atrial activation, ventricular activation, and cardiac events. Inaddition, the CRM device modifies therapy based on data received fromthe NS device, such as mean arterial pressure, systolic and diastolicpressure, and baroreflex stimulation rate.

FIG. 12 illustrates a programmer 1222, such as the programmer 822 and1122 illustrated in the systems of FIGS. 8 and 11, or other externaldevice to communicate with the implantable medical device(s) 1137 and/or1138, according to various embodiments of the present subject matter. Anexample of another external device includes Personal Digital Assistants(PDAs) or personal laptop and desktop computers in an Advanced PatientManagement (APM) system. The illustrated device 1222 includes controllercircuitry 1245 and a memory 1246. The controller circuitry 1245 iscapable of being implemented using hardware, software, and combinationsof hardware and software. For example, according to various embodiments,the controller circuitry 1245 includes a processor to performinstructions embedded in the memory 1246 to perform a number offunctions, including communicating data and/or programming instructionsto the implantable devices. The illustrated device 1222 further includesa transceiver 1247 and associated circuitry for use to communicate withan implantable device. Various embodiments have wireless communicationcapabilities. For example, various embodiments of the transceiver 1247and associated circuitry include a telemetry coil for use to wirelesslycommunicate with an implantable device. The illustrated device 1222further includes a display 1248, input/output (I/O) devices 1249 such asa keyboard or mouse/pointer, and a communications interface 1250 for useto communicate with other devices, such as over a communication network.

The above-described functions of a system, whether implemented in twoseparate and distinct implantable devices or integrated as componentsinto one implantable device, includes, but is not limited to, processesfor performing NS therapy. One process involves sustaining baroreflexstimulation. The process can be performed by a processor executingcomputer-readable instructions embedded in memory, for example.

FIG. 13 illustrates baroreflex adaptation using a relationship betweencarotid sinus pressure 1350, sympathetic nerve activity (SNA) 1351 andmean arterial pressure (MAP) 1352. Internal pressure and stretching ofthe arterial wall, such as that which occurs at the carotid sinus,naturally activates the baroreflex and the baroreflex inhibits SNA. Thecarotid sinus pressure, the SNA and the MAP are illustrated for thefollowing four time segments: (1) relatively low and constant carotidsinus pressure 1350 indicated at 1353; (2) relatively high and constantcarotid sinus pressure 1350 indicated at 1354; (3) relatively high andpulsed carotid sinus pressure 1350 indicated at 1355; and (4) a returnto a relatively high and constant carotid sinus pressure 1350 indicatedat 1356.

When the carotid sinus pressure is relatively low and constant, asillustrated at 1353, the SNA is relatively high and constant, and thepulsating MAP is relatively high. When the carotid sinus pressure isincreased to a relatively high and constant pressure at transition 1357,the SNA and MAP initially decrease due to the baroreflex and thenincrease due to the quick adaptation of the baroreflex to the increasedcarotid sinus pressure. However, when the carotid sinus pressurepulsates similar to naturally-occurring blood pressure pulses, asillustrated at 1355, the SNA and MAP decrease to relatively low levelsand are maintained at these relatively low levels. When the carotidsinus pressure changes from a pulsed to constant pressure at transition1358, the SNA and MAP both increase again due to the adaptation of thebaroreflex. The present subject matter modulates the baroreflexstimulation to mimic the effects of the naturally-occurring pulsepressure and prevent baroreflex adaptation.

FIG. 14 is a graphical illustration of the relationship between a changein blood pressure and a rate of a stimulation signal. The figureillustrates that the frequency of the stimulation signal significantlyaffects the decrease in blood pressure, which is a surrogate baroreflexparameter indicating the inhibition of SNA. The figure illustrates thata maximum decrease in blood pressure occurs at a stimulation frequencywithin a range from about 64 to about 256 Hz, and occurs approximatelyat 128 Hz.

Various embodiments of the present subject matter modulate the frequencyof the stimulation signal to modulate the blood pressure to mimic theeffects of a naturally-occurring pulse as generally illustrated at 1355in FIG. 13. Various embodiments stimulate with a frequency betweenapproximately 8 Hz and approximately 512 Hz, or various ranges withinthis range such as approximately 16 Hz to approximately 128 Hz,approximately 32 Hz to approximately 128 Hz, for example. Otherembodiments modulate other parameters of the stimulation signal to mimicthe effects of the naturally-occurring pulse, and thus prevent or reducebaroreflex adaptation. By preventing the baroreflex from adapting toincreased baroreflex activity, long-term baroreflex stimulation can beused to achieve reflex reduction in hypertension. Varying the baroreflexstimulation maintains the reflex inhibition of SNA and abates (i.e.nullify or reduce in degree or intensity) adaptation to increasedbaroreflex activity that occurs during constant stimulation.

FIG. 15 illustrates a method to periodically modulate neuralstimulation, according to various embodiments of the present subjectmatter. At 1559, it is determined whether neural stimulation is to beprovided. Upon determining that neural stimulation is to be provided,neural stimulation is applied with periodic modulation to mimicpulsatile pressure, as generally illustrated at 1560. In variousembodiments, the periodic modulation, or other variation, of the neuralstimulation signal is based on detected pulsatile information 1561 suchas a detected pulse rate 1562 and/or a detected pulse phase 1563. Someembodiments further base the periodic modulation based on detectedfeedback parameters 1564, such as detected respiration, detected nervetraffic, detected blood pressure, and the like. These feedbackparameters allow the stimulation to be tailored to achieve a desiredeffect.

FIG. 16 illustrates a neural stimulation device, according to variousembodiments of the present subject matter. The illustrated device 1621includes a controller 1623, a baroreflex stimulator 1626 and acommunications interface 1625 adapted to communicate with each otherusing bus 1665. The controller 1623 is adapted to implement a baroreflexstimulation protocol 1628 to periodically modulate the baroreflexstimulation provided by the stimulator 1626. The modulation ispreprogrammed in various embodiments. In some embodiments, themodulation is based on detected parameters, such as detected pulsatileparameters. These detected parameters are capable of being detected byanother device, such as a blood pressure monitor or implantable CRMdevice, and communicated to the device 1621 via the communicationsinterface 1625.

FIG. 17 illustrates an implantable neural stimulation (NS) device withsensing and/or detecting capabilities, according to various embodimentsof the present subject matter. The illustrated device 1721 includes acontroller 1723, a baroreflex stimulator 1726, and a communicationsinterface 1725 adapted to communicate with each other using bus 1765.The controller 1723 is adapted to implement a stimulation protocol 1728to periodically modulate baroreflex stimulation. Some device embodimentsinclude a pulsation detector 1766 to detect pulsatile information suchas pulse rate and/or pulse phase, and to communicate using bus 1765.Some device embodiments include baroreflex feedback sensors 1767 todetect nerve activity and/or a surrogate parameter of nerve activity,and to communicate using bus 1765. Examples of a surrogate parameter ofnerve activity include respiration and blood pressure.

FIG. 18 illustrates a system 1890 including an implantable neuralstimulation (NS) device 1837 and an implantable cardiac rhythmmanagement (CRM) device 1838, according to various embodiments of thepresent subject matter. The CRM device 1838 includes a pulse generator1843, a controller 1868, a communications interface 1869 and an analyzer1870 to analyze sensed activity from at least one lead. Bus 1871provides a means of communicating within the CRM device. The illustratedanalyzer 1870 includes a pulsation detector 1864. Various embodiments ofthe analyzer 1870 further includes a baroreflex feedback module 1861 todetect parameters indicative of the baroreflex such as heart rate,respiration and the like.

The NS device 1837 includes a controller 1823, a communicationsinterface 1825 and a baroreflex stimulator 1826 to stimulate abaroreceptor site or baroreflex pathway using at least one lead. Bus1865 provides a means of communicating within the NS device. Thecontroller 1823 implements a stimulation protocol 1828 to periodicallymodulate the baroreflex stimulation provided by the baroreflexstimulator 1828. Various embodiments of the NS device 1837 furtherinclude baroreflex feedback sensors 1867 to detect parameters indicativeof the baroreflex such as nerve traffic, pulse rate and the like. Theseparameters provide feedback information to the controller 1823, enablingthe controller to tailor the baroreflex stimulation to achieve desiredphysiologic results. The CRM device 1838 and the NS device 1837 areadapted to communicate with each other, as illustrated at 1872.According to various embodiments, the controller 1823 uses the protocol1828 to modulate the baroreflex stimulation using parameters provided bythe analyzer 1870 in the CRM device 1838.

FIG. 19A illustrates a pulse 1980 and FIGS. 19B-19D illustrate variousstimulation protocol embodiments to modulate a stimulation signal basedon the pulse. A simple example of a resting pulse rate is about 60 beatsper minute, which corresponds to 1 beat per second or 1 Hz. Somestimulation protocol embodiments closely correspond to the pulse. Forexample, some embodiments modulate the stimulation signal with a periodof modulation approximately equal to the pulse period (e.g. on the orderof approximately 1 Hz for resting pulse rate to approximately 2 Hz forexercise). In addition, some embodiments modulate the stimulation signalapproximately in-phase with the pulse phase, such that more stimulationis provided at higher pulse pressure and less stimulation is provided atlower pulse pressure. However, the present subject matter is not limitedto protocol embodiments that closely correlate the modulate stimulationsignals to the rate and/or phase of the pulse. The effect of thepulsatile pressure on the baroreflex is capable of being obtained usingother modulation protocols.

FIG. 19B illustrates amplitude modulation corresponding to the pulsesignal. The illustrated dotted lines 1980A and 1980B generallycorrespond to the pulse rate and phase of the pulse 1980 in FIG. 19A,and provide an envelope for the amplitude modulation of the stimulationsignal 1981. The phases of the illustrated stimulation signal 1981 andpulse 1980 are such that the timing for maximum amplitude of thestimulation signal generally corresponds to the maximum blood pressurefor pulse 1980. Other embodiments do not attempt to align the phases ofthe pulse and stimulation signal. The stimulation signal 1981 isillustrated with a low frequency (illustrated with a frequency ofapproximately 2 Hz with respect to a 60 beats per minute pulse) forsimplicity. Other frequencies can and are preferably used. For example,various embodiments provide a stimulation signal within a frequencyrange generally illustrated in FIG. 14 to increase the effectiveness ofthe signal in reducing the blood pressure. By using a more effectivefrequency for the stimulation signal, lower voltages can be used tostimulate the baroreflex. Lower voltages are generally desirable toreduce inflammation from stimulation and to prevent unintended captureof cardiac tissue, for example. The amplitude of the signal depends onthe placement of the electrodes and the tissue. Various embodimentsprovide stimulation signals with an amplitude on the order ofapproximately 100 μA to 10 mA.

FIG. 19C illustrates frequency modulation corresponding to the pulsesignal. With reference to FIG. 14, the effectiveness of a stimulationsignal in inducing the baroreflex is dependent on the frequency. Thus,various embodiments of the present subject matter vary the frequency ofthe stimulation signal 1981 between more effective and less effectivefrequencies. The frequency for the illustrated stimulation signal 1981is varied using a modulation period corresponding to the period of thepulse. However, the present subject matter is not so limited, as othermodulation periods are capable of effectively mimicking the pulsatileeffect.

The stimulation signal is illustrated with a low frequency forsimplicity. Other frequencies can and are preferably used. For example,various embodiments provide a stimulation signal within a frequencyrange generally illustrated in FIG. 14 to increase the effectiveness ofthe signal in reducing the blood pressure.

For example, the maximum effectiveness corresponds to a frequency withina range of 32 Hz and 256 Hz.

The following examples assume a stimulation signal having a frequency ofapproximately 128 Hz is relatively more effective at inducing abaroreflex, and that frequencies that are either higher or lower than128 Hz are relatively less effective at inducing a baroreflex. Theslowest frequencies 1982 in the stimulation signal 1981 are illustratedat the time of the highest blood pressure in the pulse 1980, and thehighest frequencies 1983 are illustrated at the time of the lowest bloodpressure in the pulse 1980. Thus, the frequency of the illustratedstimulation signal is modulated from approximately 128 Hz at a timecorresponding to the highest blood pressure to a larger frequency (256Hz or larger) at a time corresponding to the lowest blood pressure. Inother embodiments, which are not illustrated in the figures, the highestfrequencies in the stimulation signal are provided at the time of thehighest blood pressure in the pulse, and the lowest frequencies areprovided at the time of the lowest blood pressure in the pulse. In suchembodiments, for example, the frequency of the stimulation signal ismodulated from 128 Hz at a time corresponding to the highest bloodpressure to a lower frequency (approximately 8 to 64 Hz) at a timecorresponding to the lowest blood pressure. Other embodiments, which arenot illustrated in the figures, sweep between a relatively low frequency(e.g. 8 Hz) to a relatively high frequency (e.g. 256 Hz), and time thefrequency shift such that the stimulation signal has a frequency of 128Hz at a time that corresponds to the largest blood pressure in thepulse. Various frequency modulation embodiments closely correspond tothe pulse rate, various frequency modulation embodiments closelycorrespond to both the pulse rate and pulse phase, and various frequencymodulation embodiments do not closely correspond to either the pulserate or pulse phase but still are capable of mimicking the pulsatileeffect.

FIG. 19D illustrates a stimulation protocol that includes both amplitudemodulation and frequency modulation. Again, as provided above, thestimulation signal is illustrated with a low frequency for simplicity,and other frequencies can and are preferably used. The amplitudemodulation and frequency modulation were discussed above. For the sakeof brevity, the discussion will not be repeated here. FIG. 19Dillustrates that more than one parameter of the stimulation protocol canbe modulated to modulate the stimulation of the baroreflex.

FIG. 20A illustrates a pulse 2080 and FIG. 20B illustrates an example ofa burst frequency modulation protocol to mimic effects of pulsatilepressure. The intervals between duty cycles 2084 are varied betweenshorter and larger intervals over the course of a modulation period forthe duty cycles. The illustration shows about fourteen pulse cycles forevery duty cycle modulation period, and further illustrates astimulation frequency within each burst (or duty cycle) of approximately2 Hz with respect to a 1 Hz (60 beats per minute pulse). Again, asprovided above, the stimulation signal is illustrated with a lowfrequency for simplicity, and other frequencies can and are preferablyused. In various embodiments, the frequency of the signal within eachburst is within a range approximately 8 Hz to approximately 256.

According to various embodiments the duty cycle modulation periodcorresponds to the pulse period. A train of duty cycles are providedduring a pulse period on the order of 1 second for a resting heart rate,and the intervals between duty cycles are modulated between shorter andlarger intervals during the pulse period. According to variousembodiments, the duty cycle modulation period is larger than the pulseperiod, as generally illustrated in FIGS. 20A and 20B. A train of dutycycles are provided and duty cycle intervals are modulated betweenshorter and larger intervals over the course of a plurality of pulseperiods. With reference to FIG. 6, various embodiments maintain amaximum interval between duty cycles to be under 60 seconds (e.g. 30seconds) to be sufficient to maintain a desired blood pressure response.

Various embodiments combine the duty cycle modulation protocol with anamplitude modulation protocol, various embodiments combine the dutycycle modulation protocol with a frequency modulation protocol, andvarious embodiments combine the duty cycle modulation protocol with boththe amplitude modulation protocol and the frequency modulation protocol.

The illustrations in FIGS. 19A-D and 20A-B include sinusoidal waveforms.Various embodiments use other waveforms such as square waveforms,triangular waveforms, and the like. Thus, the subject matter of thepresent application is not limited to sinusoidal waveforms or any otherparticular waveform.

One of ordinary skill in the art will understand that, the modules andother circuitry shown and described herein can be implemented usingsoftware, hardware, and combinations of software and hardware. As such,the term module is intended to encompass software implementations,hardware implementations, and software and hardware implementations.

References to modulation and periodic modulation are provided asexamples of protocols to abate (nullify or reduce in degree orintensity) baroreflex adaptation. Other protocols to vary baroreflexstimulation can be used to abate baroreflex adaptation.

The methods illustrated in this disclosure are not intended to beexclusive of other methods within the scope of the present subjectmatter. Those of ordinary skill in the art will understand, upon readingand comprehending this disclosure, other methods within the scope of thepresent subject matter. The above-identified embodiments, and portionsof the illustrated embodiments, are not necessarily mutually exclusive.These embodiments, or portions thereof can be combined. For example,various embodiments combine two or more of the illustrated processes.Two or more sensed parameters can be combined into a composite parameterused to provide a desired neural stimulation (NS) or anti-hypertension(AHT) therapy. In various embodiments, the methods provided above areimplemented as a computer data signal embodied in a carrier wave orpropagated signal, that represents a sequence of instructions which,when executed by a processor cause the processor to perform therespective method. In various embodiments, methods provided above areimplemented as a set of instructions contained on a computer-accessiblemedium capable of directing a processor to perform the respectivemethod. In various embodiments, the medium is a magnetic medium, anelectronic medium, or an optical medium.

Although specific embodiments have been illustrated and describedherein, it will be appreciated by those of ordinary skill in the artthat any arrangement which is calculated to achieve the same purpose maybe substituted for the specific embodiment shown. This application isintended to cover adaptations or variations of the present subjectmatter. It is to be understood that the above description is intended tobe illustrative, and not restrictive. Combinations of the aboveembodiments as well as combinations of portions of the above embodimentsin other embodiments will be apparent to those of skill in the art uponreviewing the above description. The scope of the present subject mattershould be determined with reference to the appended along with the fullscope of equivalents to which such claims are entitled.

1. A system, comprising: a neural stimulator configured to generatestimulation pulses to stimulate a neural target; and a controllerconfigured to control the neural stimulator to deliver the stimulationpulses to the neural target to cause a desired response, wherein thecontroller includes a programmed stimulation protocol to maintain thedesired physiological response by varying a neural stimulation intensitywhen the stimulation pulses cause the desired physiological response. 2.The system of claim 1, wherein the neural target includes an autonomicneural target.
 3. The system of claim 1, wherein the programmedstimulation protocol is configured to vary an amplitude of thestimulation pulses when the stimulation pulses cause the desiredphysiological response.
 4. The system of claim 1, wherein the programmedstimulation protocol is configured to vary a frequency of thestimulation pulses when the stimulation pulses cause the desiredphysiological response.
 5. The system of claim 1, wherein the programmedstimulation protocol is configured to vary a stimulation duty cycle whenthe stimulation pulses cause the desired physiological response.
 6. Thesystem of claim 1, further comprising a physiological sensor, whereinthe controller is configured to use the physiological sensor to provideclosed loop control for delivering the neural stimulation pulses tocause the desired response.
 7. The system of claim 6, wherein thephysiological sensor includes a sensor selected from the group ofsensors consisting of: a respiration sensor, a nerve traffic sensor, apulse rate sensor, and a blood pressure sensor.
 8. A system fordelivering hypertension therapy, comprising: a carotid sinus stimulatorconfigured to stimulate a neural target in a carotid sinus region tolower blood pressure through a baroreflex response; and a controllerconfigured to control the carotid sinus stimulator to deliverstimulation pulses to the neural target to cause a desired baroreflexresponse, wherein the controller includes a programmed stimulationprotocol to maintain the desired baroreflex response by varying a neuralstimulation intensity when the stimulation pulses cause the desiredbaroreflex response.
 9. The system of claim 8, wherein the carotid sinusstimulator is configured to stimulate carotid sinus baroreceptors. 10.The system of claim 8, wherein the carotid sinus stimulator isconfigured to stimulate a glossopharyngeal nerve.
 11. The system ofclaim 8, wherein the carotid sinus stimulator is configured to stimulatea carotid sinus nerve.
 12. The system of claim 8, further comprising ablood pressure sensor, wherein the controller is configured to use theblood pressure sensor to provide closed loop control for delivering theneural stimulation pulses to cause the desired response.
 13. The systemof claim 8, further comprising a physiological sensor, wherein thecontroller is configured to use the physiological sensor to provideclosed loop control for delivering the neural stimulation pulses tocause the desired response, wherein the physiological sensor includes asensor selected from the group of sensors consisting of: a respirationsensor, a nerve traffic sensor, a pulse rate sensor, and a bloodpressure sensor.
 14. The system of claim 8, wherein an external deviceincludes the carotid sinus stimulator and the controller.
 15. A methodfor delivering a neural stimulation therapy, comprising: causing adesired neural stimulation response by delivering neural stimulationpulses to the neural target; and maintaining the desired neuralstimulation response by varying an intensity of the neural stimulationpulses, according to a programmed stimulation protocol, when the neuralstimulation pulses cause the desired neural stimulation response. 16.The method of claim 15, wherein causing the desired neural stimulationresponse includes using a sensed physiological parameter to provideclosed loop feedback control of the delivered neural stimulation pulsesto the neural target.
 17. The method of claim 15, wherein the neuraltarget includes an autonomic neural target.
 18. The method of claim 15,wherein varying the intensity of the neural stimulation, according tothe programmed stimulation protocol, includes varying at least oneparameter selected from the group of parameters consisting of: anamplitude of the stimulation pulses, a frequency of the stimulationpulses, and a stimulation duty cycle.
 19. A method for delivering ahypertension therapy, comprising: stimulating a carotid sinus neuraltarget to lower blood pressure through a baroreflex response, whereinstimulating the carotid sinus neural target includes: causing a desiredbaroreflex response by delivering neural stimulation to the neuraltarget; and maintaining the desired baroreflex response by varying anintensity of the neural stimulation, according to a programmedstimulation protocol, when the neural stimulate on causes the desiredbaroreflex response to maintain the desired baroreflex response.
 20. Themethod of claim 19, wherein the carotid sinus neural target includescarotid sinus baroreceptors.
 21. The method of claim 19, wherein thecarotid sinus neural target includes a glossopharyngeal nerve.
 22. Themethod of claim 19, wherein the carotid sinus neural target includes acarotid sinus nerve.
 23. The method of claim 19, wherein causing thedesired neural stimulation response includes using a sensedphysiological parameter to provide closed loop feedback control of thedelivered neural stimulation pulses to the neural target, wherein thesensed physiological parameter includes a sensed parameter selected fromthe group of parameters consisting of: respiration, nerve traffic, pulserate, and blood pressure.